In this issue, we’re sharing a case from our clinic in Phoenix, Arizona. What is interesting about this case? We always emphasize important facts for students and practitioners. It doesn’t matter what your textbook or seminar told you to do. Every patient is different, and in difficult cases, especially when attempts by other health practitioners have already been made, clinical success depends on the ability of the practitioner to use learned information as a basis but also to look beyond the recommended routine. In the presented case, a small variation in the clinical test allowed us to restore the patient’s health.
MEDICAL MASSAGE vs. UNEXPLAINED PAIN IN RIGHT LOWER EXTREMITY
Male, 47, works as a barber. Four months ago, he started feeling tingling on the lateral surface of his right leg. After a long day, the same sensations of tingling occurred along the dorsal surface of the foot. These symptoms were intermittent. Over the next two weeks, he developed numbness and a burning pain in the same areas, especially along the lateral leg.
He went to his family physician, who diagnosed him with Sciatica, prescribed muscle relaxants, and sent him to physical therapy. A physical therapist diagnosed the condition as Sciatica as a result of spasms in the piriformis muscle. After two weeks of physical therapy, he started to have excruciating pain originating in the right gluteal area, which was shooting all the way down to the top of the foot. At this point, he stopped working because he could not put pressure on his right leg.
An MRI showed no significant changes in the lumbar spine. The patient was referred to a Pain Clinic, where Vicodin and later Oxycodone were prescribed. The patient was very unhappy about these medications because they made him feel like a “zombie”. The patient also visited a chiropractor, but after the second session, the intensity of the pain had increased to an intolerable level, and he discontinued further therapy. Several acupuncture sessions helped reduce the pain intensity to a moderate level. However, the patient could work only two to three hours per day.
One of our patients referred him to our clinic. At the very beginning of the first examination session, it was very obvious that he was under a lot of stress and had begun losing hope because various treatments had not relieved his pain and suffering.
Examination showed significant sensory (numbness, tingling, burning pain) and motor (muscle weakness of the peroneal group) abnormalities along the distribution of the common peroneal nerve. The examination of the right gluteal area showed a very positive Trigger Point Test for the piriformis muscle. The Straight Leg Raise Test was also positive.
The examination of the lower back, right sacrum, and sacroiliac joint showed no significant abnormalities. There were moderately active trigger points in the gluteus maximus muscle. We confirmed the previously established diagnosis of Piriformis Muscle Syndrome and proceeded with the application of the MEDICAL MASSAGE PROTOCOL.
We used a three-sessions-per-week approach, with a four-day break after the third session to assess results. After each session, the patient felt significant pain relief, but after the four-day break, the pain returned, though less intense. We repeated the protocol twice with the same results. Considering the difficulty of the case and the intensity of the symptoms, the patient received a cortisone injection into the piriformis muscle. After the injection, he had only mild tingling on the right lateral leg and was able to return to work. However, within two weeks, the symptoms returned with the same intensity.
At this point, it was clear that, like the other health practitioners who had worked on this patient, we were on the wrong path. Since the piriformis protocol hadn’t worked and the cortisone injection didn’t provide a stable clinical result, something was happening above the piriformis muscle.
There are only five potential areas above the piriformis muscle where the spinal nerve can be irritated: intervertebral disks at the L4-L5 and L5-S1 levels, the short rotators at the same levels, the lumbar erectors at their insertion into the sacrum, the right sacroiliac joint (SI joint) and injury to the sacroiliac ligament. Despite our previous careful examination of all these areas, we decided to re-evaluate the patient as if we were seeing him for the first time. Starting with this session, the patient was not required to pay for treatment.
Intervertebral disk pathology was ruled out by an MRI, and there was no history of trauma or significant lumbar strain affecting the sacroiliac ligament. In addition, the symptoms developed slowly over one month, which excluded a sacroiliac ligament strain, which can trigger symptoms quickly. Palpatory examination of the short rotators and the pattern of pain distribution did not indicate their involvement.
Next, we examined the belly and tendinous part of the right lumbar erectors. This palpatory examination did not show any abnormalities either. Our final target was the right SI joint. All previous tests were negative, including the Compression Test for L5 spinal nerve irritation under the SI joint. However, when we reapplied the same test and slightly changed the angle of applied pressure (from the commonly recommended 45 degrees), the patient felt severe shooting pain to the foot. Because L5 is a major contributor to piriformis innervation via the gluteal nerves, the piriformis spasm was clearly secondary to irritation of the L5 spinal nerve under the right SI joint. Four sessions of the MEDICAL MASSAGE PROTOCOL targeting the right SI joint completely eliminated the clinical symptoms, and the patient was able to return to full-time work.
Compression Test (CT) for L5 Spinal Nerve
Now, let us consider the application of the CT and its variation that we experienced with this patient. The L5 spinal nerve is the only spinal nerve that, at its exit from the spinal cord, is attached to the thecal sac. The spinal cord is inside the thecal sac. This attachment makes the L5 spinal nerve less mobile. Any pressure or stretching of the L5 spinal nerve places it in a very unfavorable position because the nerve cannot give under even mild pressure or stretch.
If, let’s say, the SI joint on one side is even slightly imbalanced, the L5 spinal nerve will be mildly irritated. In that case, the patient will complain of sensory and/or motor abnormalities in the areas of the body at the end of the nerve. Later, if pressure on the nerve increases, symptoms may originate in the lower back and radiate down the same route. However, this was not our patient’s case.
The CT is 100% accurate and sensitive. The video below shows the anatomy of the area we just discussed and the recommended application of the CT on a spine model. As you can see, the thumb must be placed at 45 degrees, and the direction of application is critical. The pressure must be directed to the area where the iliac bone meets the sacrum and forms the SI joint. Thus, the CT does not target the SI joint but rather the area under it. The pressure should be strong enough to reach the L5 spinal nerve and further stretch the already irritated nerve.
In the video below, the dot marks the L5 spinous process, the dashed line marks the iliac crest, and the solid line marks the upper edge of the sacrum. The first part of the video shows the initial application of the CT (pressure at 45 degrees), which did not indicate L5 spinal nerve involvement under the right SI joint. The second part of the video shows that applying pressure more vertically at a 70-degree angle immediately triggered sciatica symptoms, indicating a positive CT. This simple fact completely changed the treatment protocol and restored the patient’s health.
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For Dr. Ross Turchaninov’s and Dr. P. Novakovic’s bios, visit Editorial Board.
Category: Case Studies
Tags: JMS 2011 Issue #4
